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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

People were supported by staff who promoted people’s rights and staff knew how to report abuse. Although improvements were required for completing safeguarding refrerals and notifications along with Mental Capacity Assessments, best interest decisions along with making a Deprivation of Liberty Safeguard referral if required. People were supported by staff who knew people well. Care plans were current and up to date although some improvements were required to some risk assessments such as accessing the garden and the local community. Referrals were made to local health care professionals when required such as the district nurse and GP. Staff had checks undertaken before starting their employment. Supervision and training was provided to staff to ensure they had relevant skills and knowledge to undertake their role. People were supported by enough staff who received supervision and had an annual appraisal. Training was a mixture of online and face to face. The provider’s training matrix monitored staff training and identified where staff needed to complete a training course. One area the provider had identified was that staff needed to attend Mental Capacity Assessment training (MCA).

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People felt supported by staff who were kind and helpful and people felt able to raise any concerns should they have any. One person told us, "I feel very safe here [but if worried] I would speak to senior staff and I’m quite definite I'd be listened to”. Another person told us, "The staff look after you, they are kind and helpful".

Improvements were required to ensuring safeguarding referrals and notifications were raised when required along with undertaking Mental Capacity Assessments and best interest decisions when needed and completing a Deprivation of Liberty Safeguarding referral. The registered manager confirmed following our site visit they had made positive improvements to ensuring notifications would be submitted in a timely manner and there was a better process in place to monitor when Mental Capacity Assessments and best interest decisions were required

Staff told us they knew how to report abuse. The management of the service confirmed some incidents had not been raised with the local authority safeguarding team. On reviewing these incidents we would have expected the management of the service to have raised these with the local authority safeguarding team and with ourselves. Following our inspection we shared our concerns with the local authority so they were aware of our findings. We will continue to monitor this service to ensure it is raising concerns as required.

People were supported by staff to manage their risks. However, some improvements were required to ensure there was a risk assessment that supported each person with their activity such as accessing the garden and the local community. Referrals were made to local health care professionals when required such as the district nurse and GP.

Staff told us they had information in care plans and handovers were an opportunity to be made aware of information so they were up to date.

People felt supported by staff with their individual needs and able to summon assistance should they need it. Comments included, “I know I can press the bell if I want but I’m fairly independent. I need help getting out of the bath and they come reasonably quickly. They assess me routinely”. Another person told us, “I’m pretty independent but anything I do want they help me with”. Another person told us, "I use the alarm call as I have panic attacks in the night – always come and make me a cup of tea and biscuits, they are very loving”.

People were supported by staff who knew them well. During the inspection we observed staff supporting people safely in a kind and caring manner.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

People felt supported by enough staff who they described as nice. Positive feedback from one person included, "People come and see if you’re ok. Staff are very good with me”.

During our inspection we observed people being supported by enough staff. This included during lunch time and with activities where staff spent time talking with people and providing them with assistance if needed.

Staff told us there was enough staff.

The registered manager's had weekly rota's in place that confirmed staff allocated to each shift.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.